NUR 130 Exam 4 Skin Integrity Test Questions and Correct Answers

Three layers -Epidermis -Dermis -Subcutaneous -Mucous membranes Functions of the skin -Protection -Temperature regulation -Psychosocial -Sensation -Vitamin D production (needing calcium) -Immunologic -Absorption -Elimination Psychosocial -How one looks -Like zits or scars -Brun victims, birth marks, vitiligo Tissue integrity -The state of structurally intact and physiologically functioning epithelial tissues -Such as the integument (including skin and subcutaneous tissue) and mucous membranes Age related differences -Infants -Children -Adolescents -Older adults Infants -Skin smooth, soft, and plaiable, -Thinner and weaker skin -Skin is more permeable to things -More permeable to heat loss, but can retain a lot of heat Adolescents -Sweat a lot -Odor on skin from bacteria -Begin to have acne and pimples Older adults -Looser skin -Lose fat and lean muscle -Lose sensation overtime -Weakended arterial and venal flow -Hair becomes thinner, same with nails -Lose subateous or oil glands -Do not bath everyday everything but only wash places that hold bacteria and odor Categories of impaired tissue integrity -Trauma/injury -Loss of perfusion -Immunological reaction -Infections and infestations -Theramal and radiation therapy -Lesions Wound classification -Intentional vs unintentional -Open vs closed -Acute vs chronic Unintentional wound -More prone to infection -Wound with rigid edges Trauma/injury -Intentional or unintentional damage -Location and extent damage Intential wound -Surgical cut or cutting one self Loss of perfusion -Pronlonged orr perfusion -Short periods of no perfusion can lead to tissue necrosis -Laying on something for too long; can happen very quickly Immunological reaction Skin is a visble indicator of an allergic response to a foreign substance or chronic immune response -One would get giver or rashes -Autoimmune disorder Infections and infestations -Skin and mucous membranes infections can results from bacteria, fungi, or viruses -Live arthropods can burron under the skin or attach to skin structures -Risk of secondary infection from scratching -Example: thrush (overprodcution of yeast) Skin disruption -Breaking of the skin Thermal or radiation injury -Sunburn -Burns -Radiation therapy (can kast several weeks after treatment has stopped) Lesions Can range from benign skin growth to invasive malignant tumors Example: Melanoma Principles of wound healing -A break in the skin increases the risk for infection - Systemic body responses (like a fever) -Adequate blood supply is essential -Normal healing occurs faster when the wound is free ot foreign material (need to thourghly clean out wound before healing starts and need a tetnius shot) -Ability to heal depends on extent of damage and the individuals overall state of health (older people tend to heal slower) -Proper nutrition is key to wound healing (Eat a lot of protein and Vitamin K) Vitamin K Helps with clotting First thing that one does before touching a wound Wash the hands Phases of wound healing -Infalmmatory phase -Granulation (Profliderative) Phase -Maturation phase